5. What is the cause of this patient s metabolic acidosis? LACTIC ACIDOSIS SECONDARY TO ANEMIC HYPOXIA (HIGH CO LEVEL)

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1 Self-Assessment RSPT 2350: Module F - ABG Analysis 1. You are called to the ER to do an ABG on a 40 year old female who is C/O dyspnea but seems confused and disoriented. The ABG on an FiO 2 of.21 show: ph 7.30 PaO torr HCO 3-12 meq/l PaCO 2 20 torr SaO 2 50% The doctor asks you to further evaluate the patient s clinical condition. You would recommend: A. Blood Glucose Level B. Chest x-ray C. Repeat the ABG D. Check COHb%/MetHb% E. Calibration of ABG machine and Co-oximeter 2. Does the patient have hypoxemia? NO 3. Does the patient have hypoxia? PROBABLY 4. List the four major causes of metabolic acidosis: A. LACTIC ACIDOSIS B. KETOACIDOSIS C. ELECTROLYTE IMBALANCE D. RENAL FAILURE 5. What is the cause of this patient s metabolic acidosis? LACTIC ACIDOSIS SECONDARY TO ANEMIC HYPOXIA (HIGH CO LEVEL) 6. You are caring for a patient in the ER of a hospital in Springfield Colorado (PB of 640 torr). The patient, who is currently in Colorado visiting a friend, is C/O dyspnea, is tachypneic and has tachycardia. The ABG results are ph: 7.41: PaO 2 : 60 mm Hg; FiO 2 :.21; PaCO 2 : 40 mm Hg; HCO 3 - : 25 meq/l. The patients hypoxemia can best be explained by I. A decreased PiO 2 II. A decreased PAO 2 III. An abnormal widening of the A-a gradient IV. Presence of atelectasis V. Presence of hypoventilation A. I and II ONLY B. II and III ONLY C. III and IV ONLY D. I and V ONLY E. I, II, and III ONLY 7. The patient is how many miles above sea level? 1 MILE (PBARO = 640, LOSE 120 mm Hg FOR EVERY MILE UP YOU GO) 8. What is the A-a gradient? [(640-47) x.21] (40 x 1.25) = (593 x.21) 50 = = = 14.5 mm Hg

2 9. You have been called for a respiratory consult on a 60-year-old patient C/O dyspnea. The ABG results are ph: 7.20; PaCO 2 : 80 torr; HCO 3 - : 26 meq/l; P Baro : 760 mm Hg; PaO 2 : 60 torr; FiO 2 :.21; RQ: 1.0. Based on these results, you would recommend: A. Initiating mechanical ventilation B. Initiating CPAP C. Increasing the FiO 2 to 40% via Venturi mask D. Placing the patient on a non-rebreather at 15 L/min E. Giving an updraft treatment with 2.5 mg of Albuterol 10. What is the A-a gradient [(760-47) x.21] (80 x 1) = (713 x.21) 80 = = = 9.7 mm Hg 11. What is the cause of the hypoxemia HYPOVENTILATION. 12. You are caring for a patient in ICU on A/C volume ventilation. The V t is 600 ml, f 12/min, Total rate 12/min, FiO 2 40%, PEEP 0, Peak flowrate of 60 L/min. ABG results 40 minutes after initiating mechanical ventilation are: ph 7.20; PaCO 2 : 80 torr; PaO 2 60 torr; HCO 3 - : 26 meq/l. You would recommend: A. Increasing the FiO 2 to 50% B. Adding +5 cm H 2 0 PEEP C. Increasing the respiratory rate D. Increasing the peak flowrate E. Adding an inflation hold 13. Should oxygenation or ventilation be corrected first? NO Why? CORRECTING THE HYPOVENTILATION WILL CORRECT THE HYPOXEMIA 14. You are caring for a patient in ICU on A/C volume ventilation. The V t is 700 ml, f 14/min, FiO 2 70%, Peak flowrate 50 L/min, PEEP 0 cm H 2 0. The ABG results are ph 7.37; PaO 2 55 torr; BP 140/100; PaCO 2 43 torr; SaO 2 83%. You would recommend: A. Increasing the f B. Increasing the V t C. Increasing the peak flowrate D. Increasing the FiO 2 to 80% E. Adding PEEP of +5 cm H Hypoxemia that results in an abnormal A-a gradient on room air but corrects after administration of 100% oxygen is referred to as A. Hypoxemia from a decreased PiO 2 B. Hypoxemia from hypoventilation C. Relative Shunt D. Absolute Shunt E. True Shunt 16. Differentiate between the relative and true shunt. TRUE SHUNT HAS A V/Q OF ZERO. RELATIVE HAS A V/Q BETWEEN ZERO AND 0.8.

3 17. You are evaluating a patient on mechanical ventilation with the following ABG results: ph 7.44; PaCO 2 : 36 torr; PaO 2 : 55 torr; FiO 2 : 35%; V t : 500 ml; f 12/min; Mode: SIMV VC; Peak Flow 60 L/min. You would recommend: A. Increase the V t B. Increase the f C. Add +5 cm H 2 0 PEEP D. Increase the FiO 2 to 45% E. Add 100 cc of mechanical deadspace 18. What other supplemental therapy could be done to improve the patient s oxygenation? BODY POSITION CHANGE, GOOD BRONCHIAL HYGEINE, SUCTION, BRONCHODILATORS 19. You are asked to conduct a respiratory consult on a patient with the following ABG results: ph 7.38, PaCO 2 : 42 torr; PaO 2 : 87 torr; HCO 3 - : 26 meq/l; FiO 2.21; A-a gradient 10 torr; P Baro 760 torr. The patient is C/O SOB on exertion and during routine activities of daily living. You suspect the patient may have an oxygenation problem due to: A. Absolute shunting B. Hypoventilation C. Relative shunting D. Low PiO 2 E. Diffusion defect 20. You are asked to evaluate a patient with the following ABG results: ph 7.32; PaCO 2 : 48 torr; PaO torr; FiO 2 :.30; P Baro 760 torr. You would: A. Decrease the FiO 2 to.21 B. Administer a bronchodilator C. Initiate mechanical ventilation D. Check the oxygen concentration the patient is wearing E. Order a shunt study 21. Calculate the PAO 2 and the A-a gradient. [(760-47) x.30] (48 x 1.25) = (713 x.3) 60 = = = - 47 mm Hg WHICH IS IMPOSSIBLE. 22. You are asked to evaluate a patient in ICU with pneumonia of the right lower lobe. The patient is on mechanical ventilation, SIMV- VC, V t 700 ml, f 12/min, FiO 2.60, PEEP +5 cm H 2 0, Peak flowrate of 65 L/min. The last ABG shows: ph 7.45; PaCO 2 35 torr; PaO 2 55 torr; HCO 3-22 meq/l. You would recommend: A. Positioning the patient on his left side B. Positioning the patient on his right side C. Positioning the patient in the prone position D. Positioning the patient supine E. Increasing the V t to 900 ml

4 23. Nursing has called you to evaluate a patient who has become lethargic and unresponsive in the last hour. The patient is on a Venturi mask at 40%. You draw an ABG and the results are: ph 7.30; PaCO 2 92 torr; PaO 2 95 torr; HCO 3-38 meq/l. You would recommend: A. Mechanical ventilation B. Increase the FiO 2 to.50 C. Decrease the FiO 2 to.28 D. Administer an updraft treatment with albuterol E. Recommend BiPAP 24. What is the maximum PaO 2 value on a FiO 2 of.40 and a normal PaCO 2? A. 150 torr B. 200 torr C. 250 torr D. 300 torr E. 350 torr 25. A ph of 7.38, PaCO 2 of 46 torr, PaO 2 of 41 torr are obtained on a patient who appears to be healthy. There is no tachycardia, tachypnea or cyanosis. Which of the following is an appropriate conclusion to draw on the basis of this information? A. The blood gas sample has a air bubble B. The blood gas sample was not mixed or warmed prior to analysis C. This is a venous sample D. The patient has chronic lung disease E. Mechanical ventilation should be initiated 26. You are called to evaluate a 25-year-old patient in the ER who was involved in a auto accident. The patient has tachycardia and is tachypneic, has frequent PVC s and appears to be in respiratory distress. No cyanosis is seen. The patient appears to be confused and disorientated. ABG results are: ph 7.35; PaO 2 92 torr; PaCO 2 35 torr; SaO 2 94% measured with co-oximeter HCO3 22 meq/l. Which of the following would you suspect to be the cause of the patients oxygenation problems? A. Hb and Hct B. BUN and Creatinine C. Lactic Acid Level D. Blood Glucose Level E. Electrolytes 27. You are working in the NICU and have been asked to place a pulse oximeter on a baby being mechanically ventilated in PCV- assist/control mode: Pressure limit 22 cm H 2 0, PEEP + 5 cm H 2 0, f 30/min, FiO 2.50, T I.6 sec. The doctor is unable to get an arterial blood sample. The SpO 2 reading is 100%. The capillary blood gases are: ph 7.35, PCO 2 45, PO 2 93 torr. You would recommend: A. Continue to monitor B. Decrease the FiO 2 while monitoring the pulse ox reading C. Raise the pressure limit D. Decrease the f E. Decrease the PEEP to 0 cm H 2 0

5 28. A patient is receiving 40% oxygen with an aerosol mask at a flowrate of 12 L/min. The patient s peak inspiratory flowrate is 38 L/min. The RCP should recommend? A. Increasing the flowrate to 15 L/min B. Maintain current settings 3:1 RATIO; 3+1=4 x 12 = YOU ARE PROVIDING 48 L/min C. Changing to an air-entrainment mask D. Inserting a heating element E. Placing the patient on a non-rebreather at 12 L/min 29. You are taking care of a patient on BiPAP with an IPAP of 12 cm H 2 0 and an EPAP of 4 cm H 2 0. The liter flow is 8 L/min. The ph is 7.42, PaCO 2 43 mm Hg, PaO 2 60 mm Hg, HCO 3-26 meq/l. You would recommend? A. Increase the IPAP B. Increase the EPAP C. Increase the IPAP and EPAP by the same amount D. Maintain current settings E. Intubate the patient and place on a T-bar 30. While reviewing an ABG result with a student respiratory therapist, you notice that the PaO 2 is 60 Hg but the SaO2 is reading 95%. The student asks you to explain these results. You would explain to her that: A. This is a normal relationship between PaO 2 and SaO 2. B. The ABG should be repeated because there is a lab error. C. The patient may be hypothermic and should have the patient s temperature evaluated. D. The patient may be acidotic. E. The patient may have polycythemia. 31. Low flow oxygen delivery devices are affected by which of the following I. Ventilatory pattern II. Liter flow of oxygen device III. Minute ventilation A. I ONLY B. II ONLY C. III ONLY D. I and III ONLY E. I, II, and III

6 32. Your patient is receiving 60% oxygen via an aerosol mask set at 10 L/min. The physician has asked you to draw an ABG. The patient s inspiratory flowrate is 40 L/min. The ABG results are as follows: ph 7.50; PaCO 2 20 torr, PaO 2 50 mm Hg, SaO 2 80%, HCO 3-24 meq/l. The physician suspects the patient is shunting and asks your opinion on further therapy. You would: A. Recommend non-invasive BiPAP B. Suggest intubation and mechanical ventilation C. Explain that the patient is not getting 60% oxygen and suggest an oxygen delivery device that can meet the patients flow demand 20 L/min TOTAL FLOW D. Explain that the patient is getting more than 60% oxygen from the oxygen delivery device and needs mechanical ventilation E. Recommend non-invasive positive pressure ventilation with the PB 840 ventilator 33. You come into a patient room to draw an ABG. The patient is on a heated aerosol mask at 40% at 12 L/min. There is no mist coming out of the reservoir tubing. You notice a large loop in the aerosol tubing and inadequate drainage into the reservoir bag. You would A. Proceed with the ABG and document an FiO 2 of 40% B. Drain the water from the tubing and proceed with the ABG; document 40% O 2 C. Drain the water from the tubing, wait 30 minutes and proceed with the ABG; document 40% O 2 D. Drain the water from the tubing, wait 30 minutes and proceed with the ABG; document 60% O 2 E. Proceed with the ABG and document an FiO 2 less than 40% 34. In which clinical situations would you place the patient on 100% non-rebreather mask? CHF, PULMONARY EDEMA, CO POISONING, TRAUMA, WAITING OR PREPARING FOR INTUBATION

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